Latest News

An article published earlier this week on the Health Data Management website discusses the issue of health insurers not complying with HIPAA transaction rules. The Medical Group Management Association (MGMA) believes the Centers for Medicare and Medicaid Services (CMS) should step up their efforts when it comes to ensuring these rules are being properly enforced.

The insurance plans comprise those on a regional and national level in addition to several government health plans. They are telling providers looking to manage electronic HIPAA transactions that the transactions are unsupported, which is a violation of the HIPAA Act. These transactions that are being deemed unsupported include referral authorization, claims status, and electronic claims, to name a few.

Providers that are looking to oversee electronic transactions may run into a couple of roadblocks. For example, they may use the HIPAA Administrative Simplification Complaint Form to file an electronic CMS complaint in regards to the insurer. However, there is the potential for that information to be displayed in a Freedom of Information Act request which may be accessible by the health plan. This, in turn, could allow the provider to be identified which may open the door to possible provider auditing retaliation.

MGMA thinks CMS may be able to take action when it comes to HIPAA transaction usage for payers. For example, CMS can choose to audit payers in relation to their standards adherence. If it is found that the rules are being violated, more aggressive measures can be taken to fine them.

To learn more, please visit

This update is by Abril Law, a law firm comprised of attorneys Jorge M. Abril and Sinead Baldwin. Our services include medical reimbursementcommercial litigation, and more. If you have any questions or wish to schedule an appointment, please call 305-373-0901 to speak with one of our attorneys. We look forward to working with you.

This information is provided for educational or informational purposes only and should not be construed as legal advice. The information is not provided in the course of an attorney-client relationship and is not intended to substitute for legal advice.